Using aggregate root cause analysis to reduce falls.

BACKGROUND: In certain categories of adverse events, Department of Veterans Affairs (VA) facilities may combine data to produce an aggregate review of the data. Individual root cause analyses are still required for the more serious adverse events. About 100 of the VA acute and long term care facilities contributed data to an analysis of results of 176 root cause analyses (RCAs) for patient falls occurring in the VA system. METHODS: Success was measured through a decreased report of falls and major injures due to falls after each organization's action plans were implemented. In addition, telephone interviews were conducted to understand success factors as well as barriers to implementation of clinical improvements. RESULTS: Of the 745 actions generated (that addressed the root cause), 435 (61.4%) had been fully implemented and another 148 (20.9%) had been partially implemented; 34.4% of the facilities reported reducing falls and 38.9% reported reducing major injuries due to falls. DISCUSSION: The action plans associated with these reductions focused on making specific clinical changes at the bedside rather than policy changes or educating staff. Specific interventions most highly associated with reductions in falls and injuries included environmental assessments, toileting interventions, and interventions that directly addressed the root cause and were the responsibility of a single person (as opposed to a group).

Using aggregate root cause analysis to improve patient safety.

The authors describe use of aggregate root cause analysis, which provides a systematic process for analyzing high-priority, frequent events.

How to make the most of failure mode and effect analysis.

Current accreditation standards issued by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) require hospitals to carry out a proactive risk assessment on at least 1 high-risk activity each year for each accredited program. Because hospital risk managers and patient safety managers generally do not have the knowledge or level of comfort for conducting a proactive risk assessment, they will appreciate the expertise offered by biomedical equipment technicians (BMETs), occupational safety and health professionals, and others. The skills that have been developed by BMETs and others while conducting job safety analyses or failure mode effect analysis can now be applied to a health care proactive analysis. This article touches on the Health Care Failure Mode and Effect Analysis (HFMEA) model that the Department of Veterans Affairs (VA) National Center for Patient Safety developed for proactive risk assessment within the health care community. The goal of this article is to enlighten BMETs and others on the growth of proactive risk assessment within health care and also on the support documents and materials produced by the VA. For additional information on HFMEA, visit the VA website at www.patientsafety.gov/HFMEA.html.

Department of Veterans Affairs patient safety program.

The Department of Veterans Affairs (VA) has been recognized for its patient safety initiatives. In 1998, a separate entity entitled the National Center for Patient Safety (NCPS) was established to promulgate and nurture the patient safety activities throughout the health care facilities of the VA. On the basis of a nonpunitive approach, NCPS fosters a culture of safety whereby clinicians report unsafe situations and close calls without fear of reprisals. The VA patient safety program stresses that reducing iatrogenic injury is best served through an examination of system and process vulnerabilities, with a focus on why something occurred rather than who is at fault. This article discusses the genesis of the VA patient safety program and reviews some of its successes.

Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system.

The authors describe HFMEA, a five-step process used to proactively evaluate a health care process, and provide examples of a team's forms and actions regarding prostate-specific antigen testing.